Archive for August, 2011

“I’m sorry, Doctor, but we can’t have you give that talk; you have a conflict of interest since you’ve been paid to do research on that medicine.”

“Well, Senator, it’s a conflict of interest for a doctor to sell those crutches in his office.”

“It is the opinion of this newspaper that physicians should declare to each patient any ownership interest they might have in a surgery center so that the patient is aware of any conflict of interest.”

And on and on the drums beat, droning incessantly and insistently about the dreaded “conflict of interest”.

In a world now run by the terminally attention deficited, with multi-tasking and synergy-seeking all the rage, we apparently have one domain in which nothing but the purest, most antiseptic, monastic and single-minded devotion to a single task and goal is acceptable: the provision of health care in America. Think about it…the simple existence of OTHER interests is de facto evidence of some nefarious CONFLICT of interest. The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this?

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. I bought pens last month for the first time in my professional career (I graduated from med school in 1986). It was weird. Who knew that there was a place called Office Max and that this huge store had not one but TWO aisles of pens to peruse?! I think it was Bics in a KMart the last time I bought a pen. Somehow this fact means that I have been making decisions for my patients based on all those pens I DIDN’T buy all these years. There’s only one problem with that: I don’t remember a single thing about even one of those pens.

And yet somehow accepting those pens is a “conflict of interest”. Seriously.

Why is it that if I somehow get something from someone, big or small, even if I perform some service or even buy something from them, that it’s a “conflict of interest” if some company or other might make money from what I do for my patient? Why is every peripheral interest that exists around the little silo in which I practice medicine–a space occupied by me, my staff, and my patient–why is that automatically a “conflict of interest” with some sort of negative connotation? That I must be doing something bad? Why not just “another interest”? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us?

Listen, I get it. There have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. I’m reviewing a med-mal case right now where the plaintiff had an eye problem which resulted in cataract surgery. The cataract surgeons are not being sued, but I looked over the surgical record and saw that they put an inferior POS lens implant in this guy’s eye, and I KNOW they did that because they own the surgery center and that lens is dirt cheap. THAT’S a conflict of interest. But for every surgery center owner like this putz I know 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is THAT a conflict of interest?

It’s not.

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or (GASP!) the one that left a couple pen lights in the office? Tell me, how and why is this a “conflict of interest”?

This trivialization of the concept of “conflict of interest” is actually weakening the protections that we should have against REAL conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene “consulting” agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients.

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these “conflicts of interest”. Who will replace them? Will the ascete cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by “specialists” who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients?

Here’s my bid: a true “conflict of interest” is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician. Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. We should stop this silliness; stop trivializing the concept of “conflict of interest” through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.

1) Tuna. I learned how to climb a rope. Did real, live rope climbs for the first time in a WOD yesterday during “31 Heroes”. Ton of fun. Both “The Heir” and Lil’bingo had done them before and used different techniques, so the WOD was preceded by a skills class taught by the boys. More fun.

What else did I learn? Well, you can scale a rope, but there’s no way a rope climb can be scaled.

Remember sometime as a kid sitting around with your buddies and playing the “if you could know the exact day you would die, would you want to” game? Remember how you answered and why? I always said “no”, partly because of the fun of the mystery of tomorrow (we never knew the gender of our children in utero, either), and partly due to a fear that I would in some way cease to be whatever and whoever I was supposed to become were I to know when I would cease becoming.

I read a silly, stupid blog post on some random fitness site (my Zite magazine offers up such nuggets occasionally) which basically said that CrossFit was OK for folks over-50 as long as you didn’t work too hard. Seriously. No mention of form -> consistency -> Intensity. It’s as if they’d stamped an expiration date on not only CrossFit’s efficacy but also all of us north of 50.

I call BS.

Our childhood parlor game notwithstanding, we move through our lives unaware of our own, personal expiration dates. Because of this we can seek a tomorrow that’s just a tiny bit better than today, physically and otherwise. But you already know that, don’t you?

3) Life coach. Clan bingo is soon to say our goodbyes to one of our dogs. Haddie, our 14 yo English Setter, the “Nanna” to my “Darlings”, is failing. She is still mostly happy and pain-free, her incontinence and insomnia posing more of a challenge for us than for her until this week. But this past week’s been tough for her, and the inescapable end is near. Dinner tonight with all assembled will be hard as we contemplate the next step. I pray for a missed wake-up call, or a long sigh as she is cuddled one last time, but…

Pets, especially dogs, are marvelous life coaches, don’t you think? They give unconditional love to their human pack, and give it from a well so deep it is essentially bottomless. They expect little, and live their lives fully in the moment at hand. Can’t you just hear it in their minds? “Breakfast? Really? That’s so cool! How did you know I was hungry?!” Their trust is implicit and nearly boundless.

I’ve always been amazed by the emotional intuition of my dogs. They seem to have a kind of emotional ESP, too, aware of what’s coming before you even get out of the car. When someone is edgy or angry the dogs are nowhere to be found–no reason to become collateral damage if you didn’t cause the problem. Show up a little bummed out, though, and there they are, velcro’d to your leg, ready to draw away your sadness with each stroke of their fur.

Yup, dogs are pretty good life coaches like that, but they also serve to teach us, to prepare us, for life’s ultimate events. We didn’t do this, but how many of you “practiced” on your dogs before you had your kids? They do need to be fed when they’rre hungry, you don’t change their diapers, but you’d better get them outside when they need to go. And with any dog that can stand up or jump there’s a fair amount of “child-proofing” necessary, isn’t there?

Since we outlive them, our dogs also prepare us for our greatest loss, the loss of loved ones. We bond with our dogs. We bathe in their love as we shower them with ours, and in return they teach us our hardest lesson: how to say goodbye.

I don’t know how I’ll be able to do it; I can’t even see my screen through the tears right now. Who, after all, is ever really ready when the expiration date actually arrives? But I’m a good student, and Haddie’s been a good teacher. We’ve had two bonus years with our dog after her stroke, and this, too, has been a learning experience. I’ve learned to be more thankful.

1) Churchtown. It’s “buggy Sunday” in and around Churchtown, PA this weekend. Clan bingo is visiting the ancestral home of Mrs. bingo. Every other Sunday the Mennonites who adhere to the ‘plain’ life drive their buggies to church, and today is one of those days.

Very calm. Very serene. Very, VERY slow on the roads!

2) Laissez-faire composing. My sister-in-law’s strategy for organic waste in Vermont. Opens up all kinds of fun economics takes on composting. How about “trickle-down composting”, or (I love this one) “supply-side composting”?

The possibilities are endless.

3) Entrepreneur. The American economy persists in its reluctance to create jobs, especially for young college grads and age 50+ who have been “displaced” in this eruption. What a great time, especially if you are young, to start your own business? Own your own job and who knows, you may end up owning more–you might end owning a business.

Marc Andreesen of Netscape fame: “Start your own company. If your startup fails, try another one. If that one fails, get back into a high-growth company to reset your resume and get more skills and experiences. Then start another company. Repeat as necessary until you change the world.”

Kinda fits pretty darned well with this “Change the World” through introducing CrossFit to the world through Crossfit.com or an Affiliate, eh?

4) Digging potatoes. There’s a thread lying there in every family, just waiting to be used to tie that family closer. Really. It’s there. Sometimes the thread is just barely visible, like that incredibly invisible but equally incredibly strong spider thread I twanged through this morning. All you need to is look for the thread, or even just to walk where the thread might be so that you could stumble through it (like me and my spider thread today).

I am back in a car on the very beginning of the 6 hour back end of a car trip Clan bingo took to pick some potatoes. No need to adjust your screen, that is not a typo: 12 hours of car time for a guy who is beside himself after 20 minutes, all to pick a potato. Why? Easy. That little potato patch, harvested in 20:00, is the thread that ties both sides of Mrs. bingo’s family. Each year, pretty much, for decades in some shape or form, Shaeffer’s and Hurst’s dig up a potato or two.

Trivial endeavor for sure, but it’s as simple and elemental as that single strand of webbing, nearly invisible yet always there, always re-strung, tying together the branches a growing family tree. For all but the most troubled families there’s a thread, a string, a connection. A priceless string.

1) “Every aspiring clown has big shoes to fill.” -Steve Rushin. Whoa. Think about that. Not only is that one of the best sentences–almost poetry–ever written, but it evokes literally volumes of imagery and text.

I’ll be pondering that all day.

2) For whom do you play your music? Whatever it is you do, whatever it is you have to offer, it’s really no different from the street corner musician, is it? You may be part of a little band of musicians, but let’s just say it’s your music for the moment. For whom do you play and why?

Do you play for an audience of passersby, each there but for a moment, only to hear the smallest dose of what it is you have to sing? If you’re to get a coin in your case you’d best be at the top of your game for that moment, and you’d best be playing your very tip top stuff. Indeed, you are likely to play a very limited repertoire in that scenario, eh? Kind of like the salesperson in a big commercial gym, armed with a stress-tested script with little opportunity to ad lib, but capable of successfully performing that script better than others and thereby achieving a measure of success. Some coinage.

Or do you rather play for a much smaller audience, one that lingers to hear the greater range of your catalog? The person who represents that tiny percentage of aficionados who not only UNDERSTAND your music, but have actually been trying find it, whether they knew that or not. This kind of music can be kinda messy, an experiment in expression, and it may not prompt all that many people to pause at your corner as they stroll through the iTunes of their lives. Indeed, even those who DO pause may find your music too difficult, too much of a challenge, too long in the ‘sinking in’ to appreciate. You get excited to have an audience only to be brought down when they walk on.

This sounds a bit more like Crossfit. The music of Crossfit.

(N.B. I read something that mentioned the metaphor here; sadly, I cannot remember where in order to give attribution.)

3) Have you had those days when you trudge into the gym, the Box, with little to no desire to be there? Beaten down and on the verge of defeat, you simply show up, punch in, go through the motions, punch out. Had some of those? Yah…me, too. It happens elsewhere in your life, too, in other places and at other times when you don’t really ‘have to’ be there, doesn’t it?

Well then, why did you show up?

There’s a continuum, I think, along a line that includes discipline, motivation, and habit. It might be a circle or a feedback loop–I’m not sure yet. The end result is something like consistency. Was it some sort of discipline that prompted you to go to the gym and do that workout when you didn’t really have any too much desire to be there? Some sort of force of will, a conscious imposition of rational to overpower emotion? Or were you simply motivated by some end-goal long before chosen, a milepost toward which you travel no matter what because the destination is so compelling? Subtle, I know, and I confess that the subtle difference between discipline and motivation escapes my vocabulary at this stage.

What I DO understand, though, is the concept of habit, and habit formation, and the consistency that arises from positive habits. You know, just like the Crossfit prescription of Form before Consistency before Intensity. Whether it’s the PULL of motivation to arrive at some wonderful destination, or the PUSH of discipline driving you there, it is the creation of habit, of consistency, that ultimately gets the job done.

Success is about building those habits, the ones that produce good outcomes. You went to the gym that day because going to the Box at that time is the habit you’ve developed; punching that clock on that day provides the consistency that will bring a giant forward leap on the next day when you show up with a spring in your step and fire in your belly. Any kind of habit that consistently moves you forward along a road to success is a habit worth creating. For example, I’m in the habit of assuming that every day in the office is gonna be a good day, unless it’s a great day, and I’ve noticed that this kind of habit is contagious.

I’m really not much of a complainer. I go to work unless I simply can’t rise from bed and crawl to the shower. The entire staff, my family, and every patient who walks into my office, all feed off my mood. No matter how I feel, how up or down I might be, on the outside it’s always a good day and I’m always feeling great. That’s the way it is, and that’s probably the way it’s supposed to be whenever you set the pace, and it’s certainly what’s expected of a doctor in the office. I get that, and that’s what I’ve done all of my adult life.

Except now. I’m feeling really lousy, and it’s so bad that I’m having a really hard time hiding it.

It’s partly physical, and it might be medical. No one, patient and doc alike, ever really thinks of the doctor as susceptible to human frailty of any type. Sick day? Yer a doctor…you don’t need no stinkin’ sick day! Just the same, there are a couple of things which just aren’t right.

My hands hurt. Pretty scary, eh? I’m an eye surgeon; the quality of my kids’ diet depends on the health of my hands. Nothing too big dealish right now, but just enough to engage my consciousness, oh, all day. And my shoulder, the one I hurt 3 years ago doing push-ups, it’s been buggin’ me after a little kayak rescue adventure on the 4th of July. The gym hasn’t been the sanctuary it’s been for me over the last couple of years. I’m a Crossfitter–we measure everything in the gym. I’m not making any PR’s (Personal Records) on repeat WOD’s (Workout of the Day) to speak of. In fact, my times and loads on repeat WOD’s are actually off by about 10% or so. Greg Glassman, the founder of Crossfit (a real, live, certified genius) has postulated that measured fitness is a proxy for health. Indeed, he posits that fitness EQUALS health. I’m a huge Greg Glassman fan, but I really hope he’s not entirely right on this one.

Is that it? Is that all this is about? A few dings after 51 years of being a knucklehead athlete?

(Laughing) Sure! It would be cool if that’s all there is! But there’s this little bump in my neck (probably just left over from a virus), and a general decrease in energy, generally poor quality sleep. My tolerance for the little inconveniences in life is nil. My ability to let the myriad little discourtesies that are directed at a doctor or a boss is at an all time low. I’ve turned into every physician’s nightmare: the doctor as a patient.

Who watches the watchers? Who looks out for those who are tasked with looking out for others? Who is there to care for those who dispense care?

Medicine of all kinds is the ultimate looking glass. Patient or doctor, you spend pretty much all of your time on one side or the other. As much as we as docs try to empathize with a patient it’s simply impossible to do any better than sympathize, even if we have the exact same symptoms or diagnosis; our experience is NEVER the same. We speak the language so our conversation with our own doctors is different. They nearly always treat us as colleagues first, patients second. We either get a pep talk or end up with the “blue-plate special” work-up.

Me? It will likely turn out to be the result of the unrelenting grind of being a doctor who takes care of patients. The countless little cuts from non-medical folks who are involved in the “care” that make it more difficult to do your job. The incessant bleating in every media outlet about the “problem with doctors”. The patient, or family member of a patient, who has received state of the art, best in class care and the best possible outcome, yet finds it necessary to complain about something. It will likely be the endless weight of carrying the financial health of 15 families on my shoulders like so many other small business owners.

When the doc does go down he/she never goes alone. Private practice or huge institutional setting, we are each an integral part of a complex micro-economic and social ecosystem. Set apart, but never truly separate. We never go down alone.

I have an image in my mind, a slow video of waves washing over a rock which sits at the mid-tide mark. It’s a substantial rock. Sturdy. Large. Not unattractive. Steady. I imagine people walking by all day, every day, occasionally glancing at the rock, but mostly just peripherally aware that it’s there. A crab underfoot might prompt a jump to safety, a daydreaming beachcomber might stub a toe, but mostly folks just don’t really think about the rock. Nobody notices that after years and years of twice daily tides the rock has started to show some wear. A tiny crack here. A little chip there.

1) Debilitating pleasure. Description used by a writer to describe his reaction to drinking wine in Paris. Gotta be a “Puritan and a French writer walk into a bar” joke there somewhere.

2) Re-entry. We have a couple of cousins in the extended bingo clan who have returned home from their freshman years in college, and one of mine who just returned from the end of what would have been his freshman year, spent recently in an extended Crossfit Kids internship (thanks Jeff and Mikki!). My Mom, Grambingo, has always said that it is the SOPHOMORE summer that was the worst. Bodes ill for the families of the cousins judging by our recent visits and chats.

I’ve written before about returning home to the primordial bed as an adult, about the disconnect and the disruption it causes for both home and visitor. The conclusion I reached is that you can, indeed, go home again; you just can’t stay.

What of our youngsters? Both of my sons have returned home with a plan to start their own business (announcement to come after they’ve gone public with the news). How’s OUR re-entry going? Well, “The Heir” lasted about 2 weeks before he declared he would move into a house with friends. No surprise there at all. Lil’bingo just got home, but it’s only post-freshman year, too soon to tell. He won’t stay forever, either, but it’ll be cool if he does stick around for awhile.

And us, Mr. and Mrs. bingo? We’re fine, thank you, but we’ve just reached another blind corner, as it were, with this parenting thing. Parenting is different again as we encounter this newer type of “re-entry”, children entering and departing, at some point presumably not to re-enter again until their bed is no longer theirs, just the primordial bed I visited at Grambingo’s. And my better 95% and I have a re-entry of our own, don’t we, as we re-enter a home built around just 2.

You CAN stay there.

3) Friendship. Friendship has a cost. There’s a price for each friendship, a certain trading level if you will. Think about your friendships, where you are financially with regard to your friends, how you talk about money together, deal with money when you are together.

People are weird about money. I was reminded about a couple of stories last week that illustrate this. I grew up with two small groups of friends, one older and one my age. We were all sorta middle middle-class economically, and our folks made all of us work for our spending money. I don’t ever remember “owing” any of these guys any money, and I don’t ever remember any of them owing me. We kinda fell into this “it’ll all work out” kinda thing; whoever had money bought the beer and/or the pizza. Clan bingo dropped in on one of these guys en masse a couple of years ago and nothing had changed. I don’t remember, but I’m sure we bought some food or some wine or something; I’m equally sure that Tom doesn’t remember, either.

When I was a young physician in training, missing both nickels to rub, Mrs. bingo and I chose to live near some college mates, all of whom were doing very well, thank you. We received many very nice invitations to spend time with them at some very lovely places in and around NYC, Dutch treat, all of which would have required both nickels and then some. We couldn’t go, of course, and our invitations for them to join us in our very modest apartment for burgers and dogs always found them busy.

Only one friend understood, the one who had less when I had more as youngsters. His family accepted all of our invitations, and his invitations were either to his home or on his dime, making it clear that it was HE who was getting the better of the deal because we were together. He remains my closest friend on earth.

I’ve been fortunate as an adult in that I’m relatively free of needs, and there have been times when I could cover the wants of my friends, or cover my wanting to cover them even if my friends were able. What’s interesting is how difficult it can be to have it be comfortable when someone is “treating”. Think about it a minute: do you feel owed when you treat or that you owe when you are treated? It took 10 years AT LEAST for my closest local friend to stop keeping score when I was the one more able, to understand that I was actually the one getting more out of the deal because he and I were doing stuff together.

There’s a cost to every friendship, a trading range if you will, and the greater the range between those involved the more difficult it can be if you look at it that way. For me, with those friendships that have passed the test of time, the money involved is nothing more than a measure of how much that friendship is worth.

2) Travel. Once again I was blown away by the generosity of the Crossfit community and Crossfit Affiliate owners. “The Heir”, Lil’bingo, and I were the guests of Mark and Crossfit Cape Cod for a vacation WOD on Thursday. As always we identified ourselves as experienced Crossfitters, but as the call was made by “The Heir”, we were NOT identified as Clan bingo. We were welcomed as old friends and without asking given a discount on the drop-in rate. Classy and classic.

I travel a bit, and I like to visit Crossfit gyms when I do. I always ask to pay, and I always ask if I will make a class too crowded. Even before identifying myself I am always welcomed and rarely asked for the drop-in fee. Talking with other Crossfitters this seems to be the norm.

We are a generous, tightly knit lot, we Crossfitters. We assume goodwill on the part of our CF brethren. In general Crossfit brings out more of our good qualities than our less than good. Heartfelt thanks once again to Mark, his bride, and the good people of Crossfit Cape Cod for another great CF experience!

3) First up. Where are you on the birth order in your family? Mrs. bingo and I are both first born. If you have children where do they lie in the birth order of the grandchildren? Again, our first two are the first of 10. It’s almost a cartoon, a caricature, how similar our experience is probably to any of yours who share this seemingly trivial trait.

Your parents got you fully assembled without an owner’s manual. Your were their grand experiment. It was a “Goldilocks” process for them, too. You know, too strict, too loose, just right. They got all kinds of “help” raising you, too. Lots of folks are pretty darned sure of how you should do this kid raising thing until they find themselves drowning in the process themselves.

Here’s the deal: “I told you so” is possibly the cruelest blow you could ever rain down on all of your “advisors” when they find themselves awash in the ebb and flow of their own parenting chores. It’s just as hard for them as it was for you, of that you can be sure. If you’ve done a pretty good job with your progeny simply hope all of those helpful color commentators were paying attention.

Be kind.

4) Want/need. Again. Up and down the fortunes go. Some stay inexorably above the “want” threshold, while for others there are dips into the realm of need. Me? Flip-flopping like a fish on the deck, up and down across the divide. How’s that going? Pretty well, actually.

It’s instructive to watch others as they struggle with this. Instructive, but also sometimes quite painful. A series of mishaps or setbacks can leave the heretofore comfortable in a ragged state of shock, so close to the “need” level that it feels as if “need” isn’t being met. The reality is that almost all of us are actually quite far removed from the real “need” threshold, but that doesn’t make the vector of the movement any less traumatic.

Some of this is reflective of expectations, what our folks would have called “counting your chickens before they’re hatched.” The bonus or raise or promotion didn’t come. That 100 member milestone is still out there on the horizon, too many months after the proforma said it would make landfall. It’s the “lottery syndrome”: we spend today as if it were already the tomorrow we are hoping to live.

Be clear-eyed in evaluating your status. Only kid yourself for fun. Want what you have. Enjoy what you have. Mrs. bingo has beaten this into me, on the way up, and also on the way down, and she’s always been right.